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Original article

British athletics muscle injury classification:

a new grading system
Editor’s choice
Noel Pollock,1 Steven L J James,2 Justin C Lee,3 Robin Chakraverty4
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▸ Additional material is ABSTRACT oedema21 22

and involvement of the
published online only. To view The commonly used muscle injury grading systems based tendon. 20 22 23
There is some lack of consistency
please visit the journal online
(http://dx.doi.org/10.1136/ on three grades of injury, representing minor, moderate regarding the relevance of distance from the muscle
bjsports-2013-093302). and complete injuries to the muscle, are lacking in origin,20–22 but the other features have repeatedly
1 diagnostic accuracy and provide limited prognostic been demonstrated to have prognostic relevance.
British Athletics Medical
Team, London, UK information to the clinician. In recent years, there have In clinical practice as well as in recent litera-
Department of Radiology, been a number of proposals for alternative grading ture24 25 the concept of the grade 0 muscle injury
Royal Orthopaedic Hospital systems. While there is recent evidence regarding the has been developed. This usually represents a clin-
Foundation Trust, prognostic features of muscle injuries, this evidence has ical syndrome of muscle abnormality but without
Birmingham, UK
Department of Radiology, not often been incorporated into the grading proposals. imaging evidence of pathology. It is of course pos-
Chelsea and Westminster The British Athletics Muscle Injury Classification proposes sible, and indeed probable, that this is often a struc-
Hospital, London, UK a new system, based on the available evidence, which tural pathology, which is undetectable with current
British Athletics Medical should provide a sound diagnostic base for therapeutic imaging modalities.26 27 Nevertheless, this ‘non-
Team, British Athletics National
decision-making and prognostication. Injuries are graded structural’ injury grade has been associated with
Performance Centre,
LoughboroughUniversity, 0–4 based on MRI features, with Grades 1–4 including quicker return to sport10 11 18 and is therefore of
Loughborough, UK an additional suffix ‘a’, ‘b’ or ‘c’ if the injury is relevance in a grading system.
‘myofascial’, ‘musculo-tendinous’ or ‘intratendinous’. Recently, the Munich consensus25 and others28
Correspondence to Retrospective and prospective studies in elite track and have proposed alternative muscle grading systems.
Dr Noel Pollock, British
Athletics Medical Team, field athletes are underway to validate the classification The Munich grading system classifies injuries as
Level 1 Outpatients, Hospital for use in hamstring muscle injury management. It is either ‘functional’ (fatigue induced, delayed onset
of St John and St Elizabeth, intended that this grading system can provide a suitable muscle soreness (DOMS), spine-related neuromus-
60 Grove End Road, London diagnostic framework for enhanced clinical decision- cular dysfunction or muscle-related neuromuscular
NW8 9NH, UK;
making in the management of muscle injuries and assist dysfunction) or ‘structural’ muscle pathology. The
with future research to inform the development of ‘functional’ terminology is problematic as clearly a
Accepted 26 June 2014 improved prevention and management strategies. number of the pathological entities which the
Published Online First Munich system describes as ‘functional’ are most
16 July 2014 likely structural pathology,27 and indeed the con-
INTRODUCTION sensus comments on MRI changes in these classes.
Muscle injuries are common in sport and account The ‘structural’ classes are further divided into
for substantial time lost from training and competi- three essential grades of muscle injury: minor, mod-
tion.1–3 They represented 48% of all injuries erate and complete. Clinical presentations of this
during track and field competition in a recent pathology, categorised as ‘structural’ rather than
International Association of Athletics Federations ‘functional’, are likely to have important functional
(IAAF) study2 and more than 30% of all injuries in elements to the diagnosis and therefore this termin-
professional football.3 The hamstrings are the most ology has some limitations.29 30
frequently injured muscle group2 and hamstring A recent study by contributors to the Munich
muscle injuries alone result in an average of consensus concluded that, as with the previous
90 days missed per club per season in professional grade 1–3 systems, the ‘structural’ part of the
soccer.4 Muscle injuries are also common in rugby Munich categorisation was helpful prognostically
union,5 6 Australian Rules football,7 basketball8 and but the ‘functional’ aspect of the system was not.31
other Olympic sports.9 However, the wide range of return to play dura-
Grading systems are important for clinicians, tions in this study suggests that truly beneficial
coaches and athletes and should provide prognostic prognostic information from this grading system is
and therapeutic direction. The most widely still lacking. The Munich proposal neglects much
used10 11 current muscle grading systems are simple of the recent evidence which demonstrates
and, whether clinical or radiological, are usually prognostic significance for site, length, tendon
based on three grades of injury which essentially involvement, MRI negative presentations and cross-
represent minor, moderate and complete injuries to sectional size of the muscle injury.10 16 20 21 23 32
the muscle.12–15 Within these widely used grading Therefore, particularly with regard to structural
systems there could be considered a lack of consist- pathology, this system does not develop muscle
ency in terminology and clarity in diagnostic injury grading substantially beyond the simplistic
entities. There is little representation of the current grade 1–3 systems currently in use which are really
To cite: Pollock N, evidence that does provide prognostic information limited in their differentiation of injury, prognostic
James SLJ, Lee JC, et al. Br J for the clinician such as length of muscle tear on ability and therapeutic relevance. With regard to
Sports Med 2014;48: MRI,10 16 MRI ‘negative’ injuries,10 17–19 distance the ‘functional’ grading aspect of the Munich con-
1347–1351. from the origin,20 cross-sectional area of sensus, despite the lack of clearly defined diagnostic

Pollock N, et al. Br J Sports Med 2014;48:1347–1351. doi:10.1136/bjsports-2013-093302 1 of 6

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Original article

entities or evidence of prognosticating ability, this may still be of relative to the muscle origin.20 With respect to hamstring injur-
use to clinicians to develop understanding and to direct treat- ies, it is proposed that the proximal third is above the lower
ment strategies. margin of the gluteus maximus and the distal third is below the
An alternative classification system proposed by Chan et al28 origin of the short head of biceps femoris.
describes an imaging categorisation based on the location and The specific muscle that has been injured should also be
type of tissue injury. There is undoubted merit in an anatomical named (figure 1).
diagnosis which may have prognostic relevance. However the
nomenclature retains the poorly defined ‘strain’ term, does not MRI
clearly define the limits of each grade, ignores MRI negative MRI may be performed on either a 1.5 or 3 T system, ideally at
injuries and the great majority of actual tears are still within the 24–48 h following injury.11 Skin markers (cod liver oil capsule)
same grade. As both MRI resolution and our understanding of should be placed at the site of the athlete’s maximum pain prior
the relevant prognostic and anatomical features of muscle injur- to imaging. The MRI study should include a combination of
ies improve, a grading system which uses these advances can be acquisitions in three orthogonal planes. The closest muscle
developed. The recent proposal by Chan et al and the Munich insertion to the injury site should be included as this will define
consensus are welcome additions that have stimulated interest in the proximal or distal extent of imaging. It is often necessary,
this area. However, the opportunity to provide a clinically rele- particularly if the athlete’s symptoms are poorly localised, to
vant, evidentially coherent and logical approach remains. cover the whole thigh to ensure an optimal study. The exact
The British Athletics Medical team provides medical support choice of sequences will, to some extent, depend on the individ-
to Great Britain international track and field athletes. A recent ual radiologist’s preference. A typical protocol would include
report on injuries in 214 elite British track and field athletes axial, coronal and sagittal short tau inversion recovery (STIR)/
over a 3.5-year time period (2010–2013) found that of the total T2-weighted fat suppressed/proton density-weighted fat sup-
1000 injuries recorded, 147 (14.7%) were hamstring-related pressed sequences followed by axial and sagittal T1-weighted
injuries (unpublished). The grading of these injuries using the sequences. The coronal and sagittal sequences are primarily
historical system demonstrated a broad prognostic value, similar used to assess the longitudinal extent of the injury and tendon
to the recently published work in football.11 However, the involvement, and the axial images allow optimal anatomical
demand of elite sport necessitates greater diagnostic accuracy information and the cross-sectional area to be defined. The slice
with the goal of providing targeted management and rehabilita- thickness of imaging acquisition should allow accurate definition
tion within more clearly defined timescales. The British of small injuries often necessitating a slice thickness of 4 mm.
Athletics Medical team have therefore developed a muscle This will often require the use of two separate axial acquisitions
injury grading system that has a clear diagnostic framework and if the whole thigh is imaged for optimum resolution.
uses the available prognostic evidence to assist in classification.
It has been primarily developed as a hamstring injury classifica- Detailed description
tion, influenced by the literature in this field, but with potential Grade 0 injuries
to be extrapolated for use in other muscle injuries. In the British Athletics Classification system grade 0 injuries are
classified as: 0a—a focal neuromuscular injury with normal
BRITISH ATHLETICS MUSCLE INJURY CLASSIFICATION MRI, or 0b—generalised muscle soreness with normal MRI or
Overview MRI characteristic of DOMS. It is recognised that there may be
There are five grades of muscle injury categorised in this clinical suspicion of a neural component to these grade 0 pre-
grading system: grade 0 through grade 4, primarily, and exclu- sentations34 and this can be represented by the addition of ‘+N’
sively for grades 1–4, based on the MRI features of the muscle to either of these injuries.
injury (see online supplementary table S1). There is clinical Grade 0a classifies a clinical presentation of focal muscle sore-
overlap between the grades but the most common clinical pre- ness usually after exercise, although it may also occur during
sentations are described as means of introduction. Grades 1–4 exercise. It is often accompanied with awareness on muscle con-
are further subcategorised into one of three diagnostic groups traction, but no or little inhibition of contraction or reduction
(a, b or c) based on the site and extent of the injury. The injury in strength on manual testing. The clinician may be able to
is classified at the highest number and letter as determined by palpate a focal area of increased muscle tone. This clinical
the injury characteristics. picture probably reflects a pathological process of microscopic
It is considered that muscle injury is an appropriate general muscle damage or peripheral nerve irritation. The grade 0a is an
term to encompass grade 0–4 injuries. In agreement with the ‘MRI-negative muscle injury’, which is described in the litera-
Munich Consensus,25 the use of the term ‘ strain’ is not recom- ture and associated with improved prognosis.10 17–19
mended and it is more appropriate to use ‘tear’ to describe Grade 0b represents generalised muscle soreness, which most
grade 1–4 injuries. commonly occurs after unaccustomed exercise, often with an
For grade 1–4 injuries, the suffix ‘a’ denotes a myofascial eccentric bias and is frequently termed DOMS. There may be
injury in the peripheral aspect of the muscle, ‘b’ an injury characteristic MRI changes with generalised, patchy high signal
within the muscle belly, most commonly at the muscle tendon change affecting several muscles.
junction (MTJ) and ‘c’ an injury which extends into the tendon.
The most common site of muscle injury is at the MTJ33 and this Grade 1–4 injuries
may be associated with more prolonged and different rehabilita- Grade 1 injuries
tion requirements than a peripheral myofascial injury. There is Grade 1 injuries are small injuries (tears) to the muscle. The
evidence that injury within the tendon is associated with a athlete will usually present with pain during or after activity.
poorer prognosis16 18 and therefore intratendon involvement The athlete’s range of movement at 24 h will usually be normal
has been categorised at the end of the scale as ‘c’. and although there may be pain on contraction, strength and
There is an additional descriptor included in the classification initiation of contraction may be well maintained on clinical
to denote the site of injury ( proximal, central or distal third) examination.

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Original article

Figure 1 Letter classification dependent on anatomical site of muscle injury. (a) Myofascial, (b) musculo-tendinous, (c) intratendinous.

Grade 1a injuries extend from the fascia and demonstrate high Grade 2b injuries occur within the muscle or, more com-
signal change on fat suppressed/STIR images within the periph- monly, at the MTJ. On MRI, the high signal change will either
ery of the muscle, no greater than 10% into the muscle and with measure between 10% and 50% of the muscle cross-sectional
a longitudinal length of less than 5 cm within the muscle. Frank area35 36 or have a longitudinal length between 5 and 15 cm.
muscle fibre disruption is not usually seen in this grade of injury There is likely to be evidence of muscle fibre disruption of less
but evidence of fibre disruption of less than 1 cm with limited than 5 cm.16
high signal change, as noted above, may still be classified in this Grade 2c injuries extend into the tendon but injury within
grade. Intermuscular fluid/haematoma on MRI may be evident the tendon is evident over a longitudinal length of less than
within the fascial planes over a greater distance. 5 cm and less than 50% of the maximal tendon diameter on
Grade 1b injuries are sited within the muscle or, more com- axial images. If the injury is near the end of the free tendon
monly, at the MTJ. High signal change is evident at this site and there may be some loss of tension in the free tendon. It may still
extends over a limited area of less than 5 cm and less than 10% of be classified as a 2c, rather than 3c, if the injury size is compat-
the muscle cross-sectional area at its maximal site. Frank muscle ible with the measurements above (figures 3–5).
fibre disruption is not usually seen in this grade of injury but evi-
dence of fibre disruption of less than 1 cm with limited high signal
change, as noted above, may still be classified in this grade.
As previously discussed, there is a poor prognostic signifi-
cance of intratendinous extension and therefore there are no
grade 1 injuries in this classification which involve disruption
within the tendon (figure 2).20 23

Grade 2 injuries
Grade 2 injuries are moderate injuries (tears) to the muscle. The
athlete will usually present with pain during activity which
necessitates them to stop activity. The range of movement of the
affected limb at 24 h will usually show some limitation with
pain on initiation of contraction, usually with detectable weak-
ness by the clinician.
Grade 2a injuries usually extend from the peripheral fascia
into the muscle. Clinical experience suggests that they may be
associated with a clinical history of pain during change of direc-
tion and manual strength testing may be less reduced with grade
2a injuries relative to other grade 2 injuries. On MRI, high
signal change will be evident from the periphery of the muscle.
The high signal change will either measure between 10% and
50% of the cross-sectional area of that individual muscle at the
site of injury or extend between 5 and 15 cm within the muscle.
Architectural fibre disruption will be less than 5 cm.16 Figure 2 Grade 1b injury to long head of biceps femoris.

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Figure 3 Grade 2a injury to lateral aspect of long head of biceps


Grade 3 injuries
Grade 3 injuries are extensive tears to the muscle. The athlete
will usually present with sudden onset pain and may fall to the Figure 5 Grade 2c injury to long head of biceps femoris.
ground. Their range of movement at 24 h is usually significantly
reduced with pain on walking. There is usually obvious weak-
ness in contraction. than 15 cm in length. There will be evidence of architectural
Grades 3a (myofascial) and 3b (muscular/musculotendinous) fibre disruption which is likely to be greater than 5 cm. Grades
will demonstrate MRI features of high signal change patterns of 3a and 3b are differentiated by the location extending to the
greater than 50% of the muscle cross-sectional area or greater periphery (3a) or being within the muscle/at the MTJ (3b).
Grade 3c (intratendinous) injuries have evidence of injury in
the tendon over a longitudinal length of greater than 5 cm or
greater than 50% of the tendon’s maximal cross-sectional area.
There is no evidence of a complete defect but there may be loss
of the usual straight margins and tendon tension suggesting
some loss of the tendon integrity (figure 6).

Grade 4 injuries
Grade 4 injuries are complete tears to either the muscle (grade
4) or tendon (grade 4c). The athlete will experience sudden
onset pain and significant and immediate limitation to activity. A
palpable gap will often be felt. There may be less pain on con-
traction than with a grade 3 injury (figure 7).


We propose a new muscle grading system that is anatomically
focused and uses available evidence on prognostication of muscle
injuries to inform the classification. It provides the clinician with
relevant anatomical and pathological information which can be
used to guide appropriate rehabilitation for the injured tissue.
This could provide the basis for advice and appropriate commu-
nication to athletes and coaches, and also a structure for future
Figure 4 Grade 2b injury to long head of biceps femoris. research in the prevention and treatment of muscle injury in

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Original article

sport. With further development, it will be feasible to incorpor-

ate some relevant clinical prognostic signs into this grading
system. These could be sport specific and, for example, may
result in a ‘+’ or ‘−’ that is added to the grade based on the pres-
ence or absence of key clinical prognostic signs.
Musculoskeletal ultrasound is being increasingly used by clini-
cians and radiologists in the assessment of muscle injury. This is
a subjective imaging modality that is dependent on the operator
and, as such, it is more difficult to define and standardise ultra-
sound findings for a new classification system. The incorpor-
ation of ultrasound imaging into this classification system should
be considered an area for future study.
It should be recognised that while this proposal is informed
by the available evidence it is currently expert opinion and
awaits validation. It is critical for muscle grading systems to be
reproducible with excellent intraobserver and interobserver reli-
ability. The clear diagnostic criteria in this grading system
should assist in this regard. MRI has excellent interobserver and
intraobserver reliability in acute hamstring injuries32 but it does
not provide reliable information on player readiness to return to
play.37 It is intended that this classification system can provide a
reproducible diagnostic framework for enhanced clinical man-
agement of muscle injury in our sport and for future research.

What are the new findings?

▸ A new muscle injury classification.

▸ Classification based on extent (grades 0–4) and site (a, b or c)
of injury.
▸ Site of injury is determined as myofascial (a), muscular/
musculotendinous (b) or intratendinous (c).
▸ Extent of injury is determined by MRI features of the muscle

Figure 6 Grade 3c injury to long head of biceps femoris.

How might it impact on clinical practice in the near future?

▸ The classification system is in current use within elite track

and field in the UK to provide validation for future clinical
and research use.
▸ As this system has an ease of use, reproducibility and a
clinically relevant and logical structure, it could have
significant impact on enhancing current clinical practice.

Acknowledgements The authors acknowledge the support and advice of

colleagues in the British Athletics medical team in the development of this grading
system including Toby Smith, John Rogers, Jarrod Antflick, Ben MacDonald, Leigh
Halfteck and Shane Kelly. The authors also acknowledge Louise Carrier for the
illustrative work.
Contributors NP contributed to conceptual design and development of grading
system, he was also manuscript author and provided clinical sports medicine
expertise. SJ contributed to the refinement of imaging specifics of the grading
system, drafting and development of concepts and provided radiological specific
expertise. JL contributed to the refinement of imaging specifics of the grading
system and provided radiological specific expertise. RCcontributed to the
development and refinement of the grading system, drafting of the article and
provided clinical sports medicine expertise.
Competing interests None.
Figure 7 Grade 4 Injury to proximal biceps femoris. Provenance and peer review Not commissioned; externally peer reviewed.

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British athletics muscle injury classification:

a new grading system
Noel Pollock, Steven L J James, Justin C Lee, et al.

Br J Sports Med 2014 48: 1347-1351 originally published online July 16,
doi: 10.1136/bjsports-2013-093302

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